A Pasadena Employment Law Firm

Committed to Helping Workers

Phone

(626) 380-9000

Mizrahi Law Intake Form Chron

Thank you for contacting us regarding your legal claims. Please fill out the form below as truthfully, accurately, and completely as possible. There will be space at the bottom for you to add any additional information you deem important. Be sure to carefully read the instructions at the end before submitting. The form is comprehensive and thorough and may take some time to fill out, so please set aside enough time to complete it. We thank you in advance for your time and efforts.

Your name

How did you find us? (If through an internet search, what keywords did you use?)

CONTACT INFORMATION

Your email (required)

Mailing address (with city, state, zip code)

Cell number

Home number

Work number

Fax number

What is the best time and way to reach you?

Are your phone and email safe to send confidential information? YesNo

SELF-IDENTIFICATION (OPTIONAL)

Date of birth

Age

Gender

Marital status

Sexual orientation

Race & national origin

Disability (if any)

Religion

If you have children, their ages

Highest level of educationLess than high schoolHigh school graduate or GEDSome collegeBachelor's degreePostgraduate degree

Feel free to share any other self-identification or category relevant to your claims

Please check each characteristic below that you believe is the basis for unlawful conduct against you

Your sex/genderYour ageYour raceYour national originYour religionYour sexual orientation (actual or perceived)Your pregnancyYour marital statusYour need to care for someone who is illYou are disabledYou are perceived as disabledYour association with someone in a protected categoryYou complained about harassment or discrimination against you or othersYou were a whistleblower who complained about unsafe practices or illegal conductPersonality ConflictsOther

If you were a whistleblower, please describe the unsafe practices and/or illegal conduct you complained about :

If you checked “Other,” please describe

Please describe the person(s) who engaged in this unlawful conduct

Over what date range did this wrongful conduct occur?

If the person who discriminated against you made negative comments about your race/sex/disability/other protected category, what was the frequency of the comments?DailySeveral times a weekWeeklySeveral times a monthMonthlySeveral times totalOnce

Describe as accurately as possible what was said to/about you that you believe is discriminatory

EMPLOYMENT INFORMATION

Date of hire

Last position title

Did you receive any promotions? YesNo

Any demotions? YesNo

Salary/Pay (yearly)

Bonus/commissions (if any)

Did you receive medical insurance? YesNo

Dental? YesNo

401(k) matching? YesNo

Pension? YesNo

Other benefits?YesNo
If yes, please describe:

Did you have a written employment contract? YesNoI don't know

Did you sign an arbitration agreement? YesNoI don't know

How would you rate your performance?

Did you receive performance reviews? YesNo
If yes, date of most recent review
What was the rating you received on your most recent review? (Please specify scale.)

Were you ever on probation? YesNo

Did you ever receive any discipline or poor evaluation? YesNo
If so, did you ever object to it?YesNo

Please describe any discipline or poor evaluation, including when it was received, what it was for, and whether you agreed with it

Describe any favorable performance reviews or positive feedback you received

Describe your job duties

Did you work over 40 hours per week? NeverRarelySometimesOftenRegularly

Were you eligible for overtime hours? YesNoI don't know

Did you receive overtime for working more than 8 hours per day or 40 hours per week? YesNoI don't know

If paid hourly, did you ever work off the clock? YesNoI don't know

Did you regularly skip lunch breaks? YesNoI don't know

EMPLOYMENT STATUS

Do you still work for this employer? YesNo

If terminated/laid off, date notified

If terminated/laid off, effective date of termination

If terminated/laid off, the person(s) who made termination decision

If terminated/laid off, were others terminated or laid off at the same time? If so, how many?

If terminated/laid off, reason(s) given for your termination/layoff

If terminated/laid off, what are the actual reason(s) you believe you were terminated?

If you were laid off in a reduction in force, please list the people in comparable positions to yours who were laid off and those who were retained. Please explain why you believe that one or more of the persons who were retained should have been laid off instead of you.

If you resigned, date you gave notice

If you resigned, effective resignation date

If you resigned, was the resignation voluntary? Please explain.

Were you offered a severance package? YesNo
If so, please describe amount offered

If applicable, do you know who replaced you? YesNo
If so, who (name, position, and how they compare to you)?

Have you been searching for a job? YesNo
If yes, describe your job search efforts

Have you found another job? YesNo
If yes, start date
If yes, compensation

Comments

REPORTING OF INCIDENT(S)

Did you report or complain about the unlawful conduct to anyone in management? YesNo

If so, please state the date(s) that you complained, the name(s) and title(s) of the persons to whom you complained, and what if anything was done by your employer in response

What were the results of the complaint/report, if any (i.e., investigation, discipline of harasser, etc.)?

Are you a member of a union? YesNo
If so, have you filed any grievance with your union? YesNo
If you filed a grievance, what was the result?

WITNESSES AND EVIDENCE

List the names, addresses, phone numbers, and relationship to you of any people that witnessed any unlawful conduct along with a brief description of what they witnessed

List the names of any other employees whom you believe were also treated unfairly, and describe how

Describe any documents that support your claims

Describe any other information that supports your claims

FINANCIAL AND EMOTIONAL HARM

Describe the financial impact that your employer’s wrongful conduct has had on you, including the types and amounts of income lost and the effects on you

Describe the effect that your employer’s wrongful conduct has had on you emotionally, psychologically, socially, and physically

Have ever you sought treatment from a doctor, psychologist, therapist, or other healthcare provider for depression or any other mental or psychological condition?YesNo
If so, please describe the type of treatment received, the dates of treatment, and the name(s) of the treater(s).

Did you have any mental health conditions (including depression or anxiety) or pre-existing emotional problems before your employer acted unlawfully toward you? YesNo
If yes, describe

Do you currently use drugs or alcohol to excess? YesNo
If yes, please explain

Since your termination, have you looked for other employment? YesNo

Please describe any efforts you have made to find other work, including dates, names of employers applied to, and responses received

Feel free to share any other information about the harm your employer caused you

OTHER ACTIONS

Have you spoken with any other attorney concerning your employment matter? YesNo
If so, please identify who/when

Have you spoken with any other person concerning your employment matter? YesNo
If so, please identify who/when

Have you filed a complaint with the EEOC? YesNo
If so, describe when, where, and what happened

Have you filed a complaint with the DFEH? YesNo
If so, describe when, where, and what happened

Have you filed a complaint with any other agency? YesNo
If so, describe when, where, and what happened

Have you received notice of any Right to Sue? YesNo
If so, date of Right to Sue

Are there any upcoming deadlines? YesNo
If yes, what are they?

Have you applied for unemployment benefits?YesNo
If so, describe when you applied and what the result has been.

Have you filed with any court? YesNo
If so, which?

Do you have a social media page or website? YesNo
If so, are they publicly viewable? YesNo
Please provide the URLs to your Facebook, LinkedIn, and Twitter Pages

Have you posted anything on social media regarding your employer or legal claims? YesNo
If so, describe

PRIOR ACTIONS

Have you ever complained about harassment, discrimination, or wrongful treatment (other than the complaints you may have described above) to your employer or to a government agency? YesNo
If so, please describe in detail the complaints made and how they were resolved

Have you ever sued anyone? YesNo
If so, describe when, where, and what happened

Have you ever been sued?YesNo
If so, describe when, where, and what happened

Have you ever filed a workers’ compensation claim for any injuries sustained at work? YesNo
If so, describe when and how it resolved

Have you ever filed for bankruptcy?YesNo
If so, provide the date

Have you ever been arrested? YesNo
If so, explain and provide the date of arrest, where, and what happened

Have you ever been convicted of a crime? YesNo
If so, explain and provide details

Have you ever been terminated or asked to resign from any other job? YesNo
If so, please describe the circumstances and the reasons given to you

Have you ever provided inaccurate information on a résumé or job application?YesNo
If so, please explain

Is there anything that you stated on your application for the job from which you were fired false, inaccurate, or misleading (including by omission)? YesNo
If so, please explain (it is critical that you be truthful)

Have you ever been accused of theft or any other misconduct? YesNo
If so, please explain

Are you currently represented by counsel/have you been represented regarding any of the above?YesNo
If so, please identify the attorney(s)

Is there anything else that we ought to know about you, your employer, your history, or any other topic?

PLEASE READ THE FOLLOWING TERMS CAREFULLY:

This form is solely for the use of Mizrahi Law for the purposes of evaluating your potential claims. The contents of this form are therefore protected by the attorney-client privilege and attorney work product doctrine.

However, submitting information via this form does not create an attorney-client relationship.

Mizrahi Law will not represent any person unless we have explicitly agreed to do so through a written retainer agreement.

Do not submit this form from a company computer or device.

Do not submit any confidential, proprietary, or sensitive information via this form.

It is important that you be truthful, accurate, and complete in answering all questions. Because your employer will likely seek to obtain all relevant records and information, it is crucial that we be made aware of all relevant information, even that which may be harmful to your case.

Please also keep in mind that legal claims are subject to a statute of limitations (a time period within which they must be brought or be forfeited). Please do not use this form to request contact regarding any time-sensitive matter.

Mizrahi Law’s practice is focused on claims of: (1) harassment, discrimination, and unlawful treatment of workers based on sex, race, disability, pregnancy, age, sexual orientation, religion, national origin, or need for family or medical leave; (2) denial of reasonable accommodations for disabilities; (3) denial of pregnancy, disability, or family leave; (4) retaliation for opposing any of the above discrimination and harassment; and (5) termination for refusing to engage in illegal activity, or for protesting reporting, or complaining about illegal activity. If we decline to take your case, this does not mean that you do not have a case, and you should consult with other attorneys immediately.

You will receive a confirmation email if the form is submitted. If you do not receive a confirmation email, this means that there was an error with your submission.

You are strongly encouraged to print a copy of this page before submission.

If you do not hear back from Mizrahi Law within three business days, please contact us by phone.

YOU MUST CHECK THE ABOVE BOX, INDICATING THAT YOU HAVE READ AND AGREE TO THE ABOVE TERMS.

Please enter the following text in the box below

You will receive a green confirmation message (and confirmation email) if the form is successfully submitted. If you receive an error message, please review the instructions, make the required corrections, and resubmit. Thank you for taking the time to fill out this form.

Client Testimonials

I didn't know it was possible to have such a caring and compassionate attorney. From the moment I met Ramit Mizrahi she was was supportive and professional. She counseled me in areas I was not familiar with in regards to employment law and worked with me to get my case settled to my satisfaction out of court. I hope I never have to hire an employment attorney again but if I do there is no other attorney I would chose.